Author: Mahmoud Eltawagny, Sherif Alkahky, Ricki Leggatt / Editor: Stephen Sheridan / Codes: / Published: 03/04/2026
A 78-year-old man with a background of stroke and antiplatelet therapy (clopidogrel), presents to the Emergency Department (ED) following a fall in his bathroom. He struck the left side of his chest against the edge of a dehumidifier. He reports severe left-sided pleuritic chest pain and shortness of breath.
On examination, he is alert and haemodynamically stable (NEWS 1), with marked tenderness and bruising over the left lateral chest wall and reduced air entry on the left. There is also mild tenderness in the left upper quadrant of the abdomen without peritonism. No other injuries are identified on secondary survey.
Initial investigations include a CT brain and chest X-ray requested by the Rapid Assessment and Triage (RAT) consultant, given the history of fall and antiplatelet use. In view of the mechanism of injury, ongoing pain and clinical findings, a CT of the thorax, abdomen and pelvis (CT TAP) is performed.
CT imaging demonstrates multiple left-sided rib fractures, associated left pulmonary contusion, and a moderate left haemothorax. The patient is commenced on supplemental oxygen; given multiple opioids, however, his pain remains severe, significantly limiting ventilation, coughing, and effective respiratory effort.
To optimise analgesia, improve respiratory mechanics, and minimise opioid requirements, an ultrasound-guided erector spinae plane block (ESPB) is performed. Following the block, the patients pain improves substantially, allowing deeper breathing and reducing oxygen requirement. The case is discussed with thoracic surgery, who has recommended admission under the local team for ongoing monitoring.
